employee benefits guide - California`s Valued Trust

EMPLOYEE BENEFITS GUIDE
HEALTH & WELFARE BENEFITS
for Certificated Employees
2014-2015
Welcome to Desert Sands Unified School District!
CONTENTS
Desert Sands Unified School District and our consultant, Burnham
Benefits, are pleased to provide an array of benefit options to meet the
diverse needs of our employees and their families. We have joined
California’s Valued Trust (CVT) to offer low-cost comprehensive
insurance along with built-in wellness and disease management
programs. This brochure provides a summary of your benefit options
and is designed to help you make choices and enroll for coverage. If
you would like more information about any of the benefits described
here, please contact the Risk Management Department:
Enrollment Information
2
Annual Notices
4
Medical Insurance
5
Dental Insurance
9
Vision Insurance
10
Julie Schmid, Benefits Office………………………. (760) 771-8513
julie.schmid@dsusd.us
Basic Life and AD&D Insurance
10
Sophai Simok, Benefits Office…………………….. (760) 771-8801
sophai.simok@dsusd.us
Employee Assistance Program
11
Voluntary Benefits
12
Wellness
13
Flexible Spending Accounts
14
Online Member Portal
15
Tentative Employee Contributions
16
Resources and Contacts
17
Section 125 Flexible Benefit Plan
Interest Form
19
Desert Sands Unified School District
Risk Management Office
Barbara Sasser, Risk Manager……………………. (760) 771-8511
barbara.sasser@dsusd.us
ENROLLMENT INFORMATION
Effective Dates / Plan Years



Medical: 07/01/2014 to 09/30/2015
Dental, Vision, Flexible Spending Accounts, Prudential Voluntary
Benefits: 07/01/2014 to 06/30/2015
Voluntary Products (Except Prudential): 09/01/2014 to 08/31/2015
Who May Enroll
All eligible employees working 4 hours or more per day, or teachers
working 50% or more, may participate in Desert Sands Unified School
District’s benefits program. Existing part-time employees who have previously declined medical benefits may participate with an increase in
hours and board approval. Your eligible dependents include:
 Legally married spouse
 Registered domestic partner
 Disabled dependent children over age 26 (with certification form)
 Children under age 26 regardless of student or marital status
District Website
You can access your medical benefits information whenever you want, from home or any place
where you have internet access, by visiting the district website. You’ll find documents posted such
as the Summary of Benefits and Coverage (SBC), annual notices, DistrictWise Newsletters, helpful
carrier resources, and more.
The district website is located at:
www.dsusd.us - Business Services / Risk Management / Health Benefits Info
2
ENROLLMENT INFORMATION
Opting Out
California’s Valued Trust (CVT) requires 100% participation for benefit eligible, full-time employees with one exception. If you are a
certificated or management employee who is currently opting-out of Medical and taking the Tax Sheltered Annuity (TSA) in lieu of
insurance, you may continue to opt-out. Please note, if you re-enroll in Medical (whether at this open enrollment or any future
open enrollment), you cannot opt-out again going forward. If you continue to opt-out, you may continue with the TSA. To continue
to opt-out and take the TSA, you will need to do the following:
 Complete the Declination form in the Risk Management Office
 Complete the TSA form for the new plan year
 Complete the paper open enrollment process for Dental, Vision and any Voluntary Benefits plan changes
When You May Enroll
Eligible employees may enroll at the following times:
 As an eligible new hire
 Each year, during annual open enrollment
 Within 30 days of a qualifying event
Documents Needed
If you have (and are continuing) Medical coverage or if you are planning to enroll in Medical insurance, you must provide
certificates for your dependents to CVT (county marriage license, birth certificate, court adoption papers, court ordered legal
guardianship papers, state registration for domestic partnerships). When completing the enrollment process, if you have scanning
capabilities at your home or worksite, you may upload your scanned documents directly to CVT. You may also fax or email your
documents to (559) 437-2965 or isabelp@cvtrust.org. If not, you will need to provide copies to Risk Management before your
benefits will be approved. If you are unable to locate these certificates, please order now to avoid the rush:
 www.usbirthcertificate.net
 www.vitalcheck.com
 www.sos.ca.gov/dpregistry
Paying For Your Coverage
You and the District share in the cost of the Medical, Dental and Vision benefits you elect. The Voluntary Benefits you elect will be
paid by you at discounted group rates. Your Medical contributions are deducted before taxes are withheld, which saves you tax
dollars. Paying for benefits before-tax means that your share of the costs is deducted before taxes are determined, resulting in
more take-home pay for you. As a result, the IRS requires that your elections remain in effect for the entire year. You cannot drop
or change coverage unless you experience a qualifying event.
Changes to Enrollment
Each year, there will be an annual open enrollment period prior to each plan’s effective date where you can make new benefit
elections for the following plan year. Once you make your benefit elections, you cannot change plans; however you may add or
remove a dependent if you experience a qualifying event. Examples of qualifying events include, but are not limited to the
following:
 Marriage, divorce or annulment
 Birth or adoption of a child
 A qualified medical child support order
 Death of a spouse or child
 A change in your dependent’s eligibility status
 Loss of coverage from another health plan
Please note that coverage for a new spouse or newborn child is not automatic. If you experience a qualifying event, you have
30 days to update your coverage and provide the required certificate. Please contact the Risk Management Department immediately to complete the appropriate election forms as needed. If you do not update your coverage within 30 days from
the qualifying event, you must wait until the next annual open enrollment period to update your coverage.
3
The Affordable Care Act and You
The Affordable Care Act (ACA) has created new options for purchasing health insurance coverage
through a Federal Health Insurance Marketplace.
Because Desert Sands Unified School District’s medical plans are considered affordable and meet
minimum value under Health Care Reform, eligible employees will not generally see lower premiums or out-of-pocket costs through the marketplace. In addition, employer contributions to your
medical benefits will be lost if you choose to purchase coverage through the marketplace, and your
portion of medical premiums will no longer be paid via payroll deductions on a pre-tax basis.
For more information, please visit www.healthcare.gov.
ANNUAL NOTICES
ERISA and various other state and federal laws require that employers provide disclosure and
annual notices to their plan participants. Desert Sands Unified School District will distribute
(via email) all federally required annual notices upon hire and during each annual open
enrollment period. Annual notices will also be posted on our district website for you to
download and read at your convenience.
Note
If you have questions
regarding annual
notices, please contact
the Risk Management
Department.
4
Annual notices include:
 Medicare Part D Notice of Creditable Coverage: Plans are required to provide each
covered participant and dependent a Certificate of Creditable Coverage to qualify for
enrollment in Medicare Part D prescription drug coverage when qualified without a
penalty. This notice also provides a written procedure for individuals to request and
receive Certificates of Creditable Coverage.
 HIPAA Notice of Privacy Practices: This notice is intended to inform employees of the
privacy practices followed by Desert Sands Unified School District’s group health plan. It
also explains the federal privacy rights afforded to you and the members of your family
as plan participants covered under a group plan.
 Women's Health and Cancer Rights Act (WHCRA): The Women's Health and Cancer
Rights Act (WHCRA) contains important protections for breast cancer patients who
choose breast reconstruction with a mastectomy. The U.S. Departments of Labor and
Health and Human Services are in charge of this act of law which applies to group health
plans if the plans or coverage provide medical and surgical benefits for a mastectomy.
 Newborns’ and Mothers’ Health Protection Act: The Newborns' and Mothers' Health
Protection Act of 1996 (NMHPA) affects the amount of time a mother and her newborn
child are covered for a hospital stay following childbirth.
 Special Enrollment Rights: Plan participants are entitled to certain special enrollment
rights outside of Desert Sands Unified School District’s open enrollment period. This
notice provides information on special enrollment periods for loss of prior coverage or
the addition of a new dependent.
 Medicaid & Children’s Health Insurance Program: Some states offer premium assistance
programs for those who are eligible for health coverage from their employers, but are
unable to afford the premiums. This notice provides information on how to determine if
your state offers a premium assistance program.
 Summary of Benefits and Coverage (SBC): Health insurance issuers and group health
plans are required to provide you with an easy-to-understand summary about your
health plan’s benefits and coverage. The new regulation is designed to help you better
understand and evaluate your health insurance choices.
MEDICAL INSURANCE
HMO Medical Plans – Kaiser Permanente
With the Kaiser Permanente Health Maintenance Organization (HMO) plans, services must be obtained at a Kaiser facility, except in
the case of emergency. Kaiser integrates all elements of healthcare such as physicians, medical centers, pharmacy and
administration in one convenient facility. In addition, Kaiser offers online tools so you can email your doctor’s office, make
appointments, refill prescriptions, and more.
Kaiser HMO plan options available:
 Kaiser Traditional HMO Medical Plan
 Kaiser HMO Wellness Medical Plan: This plan combines traditional health coverage along with resources to help you make
healthy changes. Plus, you’ll have the opportunity to earn up to $400 in rewards.
HMO Medical Plans – Blue Shield
With the Blue Shield of California Health Maintenance Organization Access+ (HMO) plans, you will be required to select a Primary
Care Physician (PCP) within the Blue Shield Access+ HMO network. Your PCP will coordinate all of your medical care. You will
receive benefits only if you use the doctors, clinics and hospitals that belong to the medical group in which you are enrolled, except
in the case of an emergency. You can receive referrals from your PCP or self-refer to specialists within your PCP’s medical group for
a higher copay using the Access+ feature of the plan. All HMO plan options offer prescription drug benefits through CVS/Caremark.
Blue Shield HMO plan options available:
 Blue Shield HMO Medical Plan 1
 Blue Shield HMO Medical Plan 2
 Blue Shield HMO Medical Plan 3
PPO Medical Plans – Blue Shield
The Blue Shield of California Preferred Provider Organization (PPO) plans allow you to direct your own care. You are not limited to
the physicians in the PPO network and you may self-refer to specialists. If you receive care from a physician who is a member of the
PPO network, a greater percentage of the entire cost will be paid by the insurance plan. You may also obtain services using a nonnetwork provider; however, you will be responsible for the difference between the covered amount and the actual charges and
you may be responsible for filing claims. All PPO plan options offer prescription drug benefits through CVS/Caremark.
Blue Shield PPO plan options available:
 Blue Shield PPO Medical Plan 3B
 Blue Shield PPO Medical Plan 5B
 Blue Shield PPO Medical Plan 7B
 Blue Shield High Deductible Health Plan (HDHP) PPO Medical Plan: This plan requires that you meet an annual deductible
before medical and prescription drug benefits are covered. You’ll pay only 20% of the cost after you have met the deductible.
This plan also meets the requirements for a Health Savings Account (HSA). Call Risk Management for additional details.
 Blue Shield PPO Wellness Medical Plan: You’ll gain access to wellness resources and have the opportunity to earn up to $400 in
wellness credits which can reimburse you for deductible and coinsurance expenses.
Alere’s Health Management Program:
PPO members and dependents with qualifying chronic conditions are eligible to participate in Alere’s Health Management
Program. This program will provide you with the facts you need to know about your condition to help you slow disease
progression, lessen the effects, and help you live a healthier life. It’s personal, private and it’s available to you at no additional cost.
Start today by calling (877) 864-1327.
MDLIVE:
PPO members and dependents can call MDLIVE for 24/7/365 access to board-certified doctors by online video, phone or secure
email for a $5 copay. Contact MDLIVE if you are considering the ER or urgent care for a non-emergency medical issues, if your
primary care physician is not available or if you are traveling. MDLIVE providers practice primary care, pediatrics, family and
emergency medicine, and have incorporated MDLIVE into their practice to provide convenient access to quality care. Start today by
calling (888) 632-2738 or registering at www.mdlive.com/cvt.
5
MEDICAL INSURANCE
Kaiser
Traditional
HMO
Kaiser
Blue Shield
Blue Shield
Blue Shield
Wellness HMO
HMO 1
HMO 2
HMO 3
Lifetime Maximum
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Deductible (Annual)
- Individual
- Family
None
None
None
None
None
None
None
None
None
None
Co-Insurance (Plan Pays)
100%
100%
100%
100%
100%
Office Visit Copay
- Primary Care Physician
- Specialist
$15 Copay
$15 Copay
$20 Copay
$40 Copay
$10 Copay
$30 Access+
$15 Copay
$30 Access+
$25 Copay
$40 Access+
Out-of-Pocket Maximum
- Individual
- Family
$1,500
$3,000
$1,500
$3,000
$1,000
$2,000
$1,500
$3,000
$3,500
$6,000
Inpatient Hospitalization
100%
$500/Admin
100%
$250/Admin
$750/Admin
Max 3 Copays/Adm
Outpatient Lab and X-Ray
100%
$10 Copay
100%
100%
100%
Emergency Services
$50 Copay
$35 Copay
$100 Copay
$100 Copay
$150 Copay
Urgent Care
$15 Copay
$20 Copay
$10 Copay
($50 Copay Out
of Service Area)
$15 Copay
($50 Copay Out
of Service Area)
$25 Copay
($50 Copay Out
of Service Area)
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Not Covered
Not Covered
$10 Copay
$10 Copay
$10 Copay
30 Visits Per Year
30 Visits Per Year
30 Visits Per Year
Medical
Plan Features
Preventive Care
- Immunizations
- Children
- Adults
Chiropractic
Prescription Drugs
Plan Features
Kaiser
Kaiser
Blue Shield
Blue Shield
Blue Shield
Retail Pharmacy
- Generic Formulary
- Brand Name Formulary
- Non-Formulary
- Supply Limit
$5 Copay
$10 Copay
N/A
30 Days
$10 Copay
$25 Copay
N/A
30 Days
$5 Copay
$10 Copay
$25 Copay
30 Days
$10 Copay
$20 Copay
$35 Copay
30 Days
$15 Copay
$30 Copay
$45 Copay
30 Days
Mail Order Pharmacy
- Generic Formulary
- Brand Name Formulary
- Non-Formulary
- Supply Limit
$10 Copay
$20 Copay
N/A
31-100 Days
$20 Copay
$50 Copay
N/A
31-100 Days
$10 Copay
$20 Copay
$50 Copay
90 Days
$20 Copay
$40 Copay
$70 Copay
90 Days
$30 Copay
$60 Copay
$90 Copay
90 Days
6
MEDICAL INSURANCE
Blue Shield
Blue Shield
Blue Shield
Blue Shield
PPO 3B
PPO 5B
PPO 7B
HDHP PPO
Blue Shield
Wellness
PPO
Lifetime Maximum
$5,000,000
$5,000,000
$5,000,000
$5,000,000
$5,000,000
Deductible (Annual)
- Individual
- Family
$100
$300
$100
$300
$250
$750
$1,250
$3,000
$500
$1,000
Co-Insurance (Plan Pays)
100%
90%
80%
80%
90%
Office Visit Copay
- Primary Care Physician
- Specialist
$20 Copay
$20 Copay
$30 Copay
$30 Copay
$30 Copay
$30 Copay
Ded, 80%
Ded, 80%
$20 Copay
$40 Copay
Out-of-Pocket Maximum
- Individual
- Family
Ded Only
Ded Only
Ded + $300
Per Person
Ded + $1,000
Per Person
Ded + $3,000
Ded + $7,100
Ded + $500
Per Person
Inpatient Hospitalization
Ded, 100%
Ded, 90%
Ded, 80%
Ded, 80%
Ded, 90%
Outpatient Lab and X-Ray
Ded, 100%
Ded, 90%
Ded, 80%
Ded, 80%
Ded, 90%
Ded, $75 Copay
Ded, $75 Copay
Ded, $75 Copay
Ded, 80%
Ded, $75 Copay
$20 Copay
$30 Copay
$30 Copay
Ded, 80%
$20 Copay
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Ded, 100%
Ded, 90%
Ded, 80%
Ded, 80%
Ded, 90%
13 Visits Per Year
13 Visits Per Year
13 Visits Per Year
13 Visits Per Year
13 Visits/Year
CVS /
Caremark
CVS /
Caremark
CVS /
Caremark
CVS /
Caremark
CVS /
Caremark
Retail Pharmacy
- Generic Formulary
- Brand Name Formulary
- Non-Formulary
- Supply Limit
$7 Copay
$15 Copay
$30 Copay
30 Days
$7 Copay
$15 Copay
$30 Copay
30 Days
$7 Copay
$15 Copay
$30 Copay
30 Days
Ded, 80%
Ded, 80%
Ded, 80%
30 Days
$7 Copay
$25 Copay
$40 Copay
30 Days
Mail Order Pharmacy
- Generic Formulary
- Brand Name Formulary
- Non-Formulary
- Supply Limit
$15 Copay
$35 Copay
$70 Copay
90 Days
$15 Copay
$35 Copay
$70 Copay
90 Days
$15 Copay
$35 Copay
$70 Copay
90 Days
Ded, 80%
Ded, 80%
Ded, 80%
90 Days
$15 Copay
$60 Copay
$90 Copay
90 Days
Medical
Plan Features
Emergency Services
Urgent Care
Preventive Care
- Immunizations
- Children
- Adults
Chiropractic
Prescription Drugs
Plan Features
CVS / Caremark Generic Versus Brand Drugs:
For any brand drug with a generic equivalent available, the generic will be dispensed regardless of what a physician writes. The physician
can specify “Dispense as Written” (DAW) or a plan participant can choose a brand drug, but they will always pay the generic c opay plus the
cost difference between the brand and generic when a brand name drug is selected and a generic is available.
7
MEDICAL INSURANCE
Finding a Kaiser Permanente Medical Provider:
Go to www.kaiserpermanente.org or call (800) 464-4000.
Finding a Blue Shield HMO Medical Provider:
Go to www.blueshieldca.com or call (888) 235-1765. Refer to the Access+ HMO network when prompted.
Finding a Blue Shield PPO Medical Provider:
Go to www.blueshieldca.com or call (888) 235-1765. Refer to the PPO network when prompted.
Tips For Using Your Medical Plan

Utilize your free preventive care benefits to stay healthy:

Use urgent care centers versus hospital emergency rooms whenever possible:
Preventive care benefits are covered at no charge to you. Regular preventive care can reduce the risk of disease, detect
health problems early, protect you from higher costs down the road, and most importantly… save your life! Take advantage
of these no cost benefits now to hopefully avoid major illnesses and costs in the future.
Frequently, patients seek the services of the hospital emergency department for ailments or injuries that could be treated
more economically, and just as effectively, at an urgent care center. It is not always easy to determine when you should
choose urgent care over the hospital emergency department. The following lists offer some guidance, but are not necessarily
all-inclusive.
Examples of URGENT CARE situations:
Examples of EMERGENCY situations:
Any illness or injury that would prompt you to see your
primary care physician
Any accident or illness that may lead to loss of life or limb,
serious medical complication or permanent disability
INCLUDING BUT NOT LIMITED TO:
 Accidents and falls
 Sprains and broken bones
 Back problems
 Breathing difficulties
 Abdominal pain
 Minor bleeding/cuts
 High fever
 Vomiting, diarrhea or dehydration
 Severe sore throat or cough
 Mild to moderate asthma
INCLUDING BUT NOT LIMITED TO:
 Chest pain*
 Seizures
 Shock
 No pulse
 Unconscious or catatonic state
 Sudden dizziness, loss of coordination or balance
 Severe abdominal pain
 Severe or uncontrollable bleeding
 Broken bones or compound fractures
 Severe difficulty breathing or shortness of breath
 Spinal cord or back injury
 Severe burns
 Major head injuries
 Ingestion of poisons or obstructive objects
 Animal, snake or human bites
*If you believe you may be experiencing a heart attack, call 911 immediately! Do not drive yourself to the emergency room!

Use generic and over the counter drugs when available:

Use the mail-order prescription drug benefit for maintenance medications:
8
The best way to save on prescriptions is to use generic or over the counter medications as opposed to brand name drugs.
The mail order pharmacy is a fast, easy and convenient way to save time and money on your maintenance medications. You
can order additional supplies of medication at a discount. See carrier provisions for details.
DENTAL INSURANCE
PPO Dental Plans
With the Delta Dental and MetLife Preferred Provider Organization (PPO) Dental plans, you may visit a PPO dentist and benefit
from the negotiated rate or visit a non-network dentist. When you utilize a PPO dentist, your out-of-pocket expenses will be less.
You may also obtain services using a non-network dentist; however, you will be responsible for the difference between the covered
amount and the actual charges and you may be responsible for filing claims. Plan options available:
 Delta Dental PPO Dental Plan
 Delta Dental PPO Incentive Dental Plan: Under this plan, Delta Dental pays 70% of the allowed fees for covered diagnostic,
preventive, basic, and major services during the first year you are eligible. This percentage will increase 10% each year (to a
maximum of 100%) for each family member, provided that person visits the dentist at least once during the year. If a family
member does not use the plan during a calendar year, the percentage remains at the level reached the previous year. If a
family member becomes ineligible for benefits and later regains eligibility, the percentage will drop back to 70%.
Plan Features
Delta Dental
PPO
Network
Calendar Year
Maximum Benefit
Deductible (Annual)
- Individual
- Family
Non-Network
$2,000
Delta Dental
PPO Incentive
Network
Non-Network
$2,700
$2,500
MetLife
PPO
Network
Non-Network
$2,500
None
None
None
None
None
None
None
None
None
None
None
None
100%
4 Per Year
50%
4 Per Year
70% - 100%
2 Per Year
70% - 100%
2 Per Year
100%
3 Per Year
100%
3 Per Year
Basic (Plan Pays)
100%
50%
70% - 100%
70% - 100%
90%
80%
Major (Plan Pays)
100%
50%
70% - 100%
70% - 100%
60%
50%
Prosthodontics
50%
50%
50%
50%
60%
50%
Preventive (Plan Pays)
Cleanings
Orthodontia
(Child(ren) / Adults)
80% with
$2,000 Lifetime Maximum
Not Covered
50% with
$1,500 Lifetime Maximum
Finding a Delta Dental Provider:
Go to www.deltadentalins.com or call (866) 499-3001. Refer to the Premier or PPO network when prompted.
Finding a MetLife Dental Provider:
Go to www.mybenefits.metlife.com/dental or call (800) 942-0854.
Tips For Using Your Dental Plan

Use contracted network providers when possible.

Ask for a predetermination of benefits.

Have dental checkups regularly.
Under the PPO plan, contracted network providers have rate agreements with insurance companies for services rendered. If
you use a non-network provider, your out-of-pocket expenses will be higher and you may be subject to balance billing.
We strongly recommend you ask your dentist for a predetermination if total charges are expected to exceed $300. Predetermination enables you and your dentist to know in advance what the payment will be for any service that may be in question.
Routine dental visits not only preserve your smile, but they can provide an opportunity for the early detection of serious diseases such as diabetes.
9
VISION INSURANCE
The MES Vision and VSP Vision plans provide professional vision care and high quality lenses and
frames through a broad network of optical specialists. You will receive richer benefits if you utilize
a network provider. If you utilize a non-network provider, you will be responsible to pay all charges
at the time of your appointment and will be required to file an itemized claim with MES Vision or
VSP Vision. Plan options available:
 MES Vision plan
 VSP Vision plan
Note
Regardless of your
age or physical
health, it’s
important to have
regular eye exams.
Adults should have
their eyes tested to
keep their
prescriptions
current and to
check for early
signs of eye
disease. For
children, eye
exams can play an
important role in
normal
development.
MES Vision
PPO
Plan Features
Examination
- Ophthalmologist
- Optometrist
VSP Vision
PPO
$20 Copay
$20 Copay
$60 Allowance
$50 Allowance
$20 Copay
$20 Copay
$45 Allowance
$45 Allowance
100%
100%
100%
$89.50 Allowance
$43 Allowance
$60 Allowance
$75 Allowance
$75 Allowance
100%
100%
100%
$50-$160 Allowance
$45 Allowance
$65 Allowance
$85 Allowance
$85 Allowance
Frames
100%
$40 Allowance
$120 Allowance
$47 Allowance
Contact Lenses
(in lieu of frames/lenses)
Lenses
- Single Vision
- Bifocal
- Trifocal
- Progressive
- Cosmetic/Elective
Frequency
- Examination
- Lenses
- Frames
- Contact Lenses
$100 Allowance
$100 Allowance
12 Months
12 Months
24 Months
12 Months
(in lieu of frames/lenses)
$105 Allowance
$105 Allowance
12 Months
12 Months
24 Months
12 Months
Finding an MES Vision Provider:
Go to www.mesvision.com or call (800) 877-6372 to find a provider near you. The
MES Vision network includes access to independent ophthalmologists and
optometrists, as well as Costco, LensCrafters, Pearle Vision, Sam's Club, Sears
Optical, Target Optical and Wal-mart retail stores.
Finding a VSP Vision Provider:
Go to www.vsp.com or call (800) 877-7195 to find a provider near you. VSP has
the largest network of private-practice eye care doctors in the industry. VSP’s
network includes 50,000 access points nationwide. VSP also contracts with Costco
Optical, Eye Care Centers of America / Visionworks, and other affiliate retail
providers. Please note, benefits may vary at affiliate locations.
10
VALUE OPTIONS EMPLOYEE ASSISTANCE PROGRAM
The Employee Assistance Program (EAP) through ValueOptions provides employees and their family members with free,
confidential assistance to help with personal or professional problems that may interfere with family or work responsibilities and
obligations.
Services include:
 Counseling Sessions: Employees and their family members can receive up to 6 counseling sessions per person, per year
(maximum of 2 episodes/courses of treatment)
 Telephone Referrals: Services are available 24 hours a day, 7 days a week via a toll-free nationwide number
 Work/Life Services: Specialists refer employees to options and provide support, guidance, and informational materials to
empower them to make informed choices about child care, elder care and assistance with other daily life issues
 Legal-Financial Solutions: Referral services, a free 30 minute legal consultation (either face-to-face or telephonic) and a 25%
discount if further services are needed
 Achieve Solutions Website Access: A dynamic online resource with information, tools and other resources on more than 200
topics, including depression, stress, anxiety, alcohol, marriage, grief and loss, child/elder care and work/life balance
Accessing the EAP:
To access EAP benefits, go to www.achievesolutions.net/cvt or you may call (877) 397-1032 to be immediately
connected to an EAP counselor.
11
VOLUNTARY BENEFITS
Voluntary Term Life - Prudential
You may elect to purchase Voluntary Term Life insurance at discounted group rates provided by Prudential. You pay for this
coverage with after-tax dollars through convenient payroll deductions.
Employee
You may purchase coverage for yourself in increments of $10,000 up to a maximum benefit of $500,000, not to exceed 5 times
your annual salary.
Spouse
If you buy coverage for yourself, you may also purchase coverage for your eligible spouse. Benefits for your spouse are available in
increments of $10,000 to a maximum benefit of $500,000 and may not exceed 100% of your employee election.
Children
If you buy coverage for yourself, you may also purchase coverage for your eligible dependent child(ren) in the following amounts:
$2,500, $5,000, $10,000.
Guarantee issue is a pre-approved amount of coverage that does not require you to provide proof of good health, and is available
to you during your initial eligibility period (upon hire). Guarantee issue is available in the following amounts:
 Employee = 2 times your annual salary to $100,000
 Spouse = $20,000
 Child(ren) = Entire benefit amount
If you are no longer in your initial eligibility period, you may enroll in Voluntary Life insurance anytime during open enrollment as
long as you provide proof of good health. To provide proof of good health, you will be asked to complete a health questionnaire
and are subject to insurance carrier approval. Prudential may approve or decline coverage based on a review of your health
history.
Voluntary Term AD&D – Prudential
You may elect to purchase Voluntary AD&D insurance at discounted group rates provided by Prudential. You pay for this coverage
with after-tax dollars through convenient payroll deductions.
Employee
You may purchase coverage for yourself in the following benefit amounts: $10,000, $25,000, $50,000, $100,000, $250,000 or
$500,000. Amounts exceeding $100,000 may not exceed 10 times your annual salary.
Spouse
If you buy coverage for yourself, you may also purchase coverage for your eligible spouse. Benefits for your spouse are available for
60% of the employee principal amount (less $2,000).
Children
If you buy coverage for yourself, you may also purchase coverage for your eligible dependent child(ren). Benefits for your children
are available for 25% of the employee principal amount (less $2,000 and not to exceed $50,000).
12
VOLUNTARY BENEFITS
Permanent Life
Desert Sands Unified School District offers you the opportunity to purchase Permanent Life Insurance at discounted group rates.
This plan protects your family or other beneficiaries in the event of your death. Permanent Life is portable, which means that you
can keep it should you change jobs or retire, with no increase in premiums as long as the District participates in the group plan.
Permanent Life options available:
 American Fidelity
 American Fidelity (underwritten by Texas Life)
Accident Only Insurance – American Fidelity
American Fidelity’s Limited Benefit Accident Only insurance plan may help you with the rising costs associated with an accident
injury or death. Benefits include accident emergency treatment, medical imaging, inpatient confinement, ambulance and more.
Several benefit plan options are available.
Cancer Insurance – American Fidelity
If you are diagnosed with cancer, American Fidelity’s Limited Benefit Cancer insurance plan may help you maintain your standard
of living. Benefit payments can be used however you’d like, including house payments, utilities, and meals/lodging expenses. This
policy is portable, which means that you can keep it should you change jobs or retire, with no increase in premiums. Several benefit
plan options are available. Please note, this policy must be in place prior to a cancer diagnosis.
Legal Plan – Hyatt Legal
Desert Sands Unified School District offers you the opportunity to purchase Legal Services through Hyatt Legal Plans at discounted
group rates. You pay for this coverage with after-tax dollars through convenient payroll deductions. This plan provides coverage for
a number of legal matters such as will preparation, buying or selling a primary home, document review, civil litigation defense and
telephone and office consultations for numerous matters (except employment related), business or pre-existing matters.
Long Term Care - Unum
Long Term Care Insurance provides benefits to help you pay for care during a chronic illness or if you are unable to perform,
without substantial assistance from another individual, two or more activities of daily living such as eating, bathing, continence,
dressing toileting, transferring, or if you require substantial supervision by another individual to protect your health and safety due
to severe cognitive impairment (such as Alzheimer’s disease or mental illness).
WELLNESS
Desert Sands Unified School District is committed to promoting the mental and physical wellbeing of our employees. With the Fit
for Life program, employees have access to:
 Flu Shots – free of charge at local CVS pharmacy
 Health screenings hosted at annual health fair: total cholesterol & high density lipids (TC/HDL), blood pressure, body mass
index (BMI) and glucose.
 The district’s Wellness Committee provides employee fitness programs, educational lectures and voluntary group hikes
through WOW! Working on Wellness! Event dates and activities are listed on the District calendar. All programs are opened
to the DSUSD community. Be a WOW! participant!
13
FLEXIBLE SPENDING ACCOUNTS
Important
Note About
the FSA
FSAs offer sizable tax
advantages. The tradeoff is that these
accounts are subject to
strict IRS regulations,
including the use-it-orlose-it rule. According
to this rule, you must
forfeit any money left
in your account(s) after
your expenses for the
year have been
reimbursed. The IRS
does not allow the
return of unused
account balances at
the end of the plan
year, and remaining
balances cannot be
carried forward to a
future plan year. We
encourage you to plan
ahead to make the
most of your FSA
dollars. If you are
unable to estimate
your health care and
dependent care
expenses accurately, it
is better to be
conservative and
underestimate rather
than overestimate
your expenses.
You can set aside money in Flexible Spending Accounts (FSA) before taxes are deducted to pay
for certain health and dependent care expenses, lowering your taxable income and increasing
your take home pay. Only expenses for services incurred during the plan year are eligible for
reimbursement from your accounts. You choose how you want to receive reimbursement for
your eligible expenses. You may use a debit card provided by American Fidelity, sign up for
direct deposit to your bank account or you may have a check sent to your home.
Please remember that if you are using your debit card, you must save your receipts, just in case
American Fidelity needs a copy for verification. Also, all receipts should be itemized to reflect
what product or service was purchased. Credit card receipts are not sufficient per IRS guidelines.
Medical Expense Reimbursement Account
This plan is used to pay for expenses not covered under your health plans, such as deductibles,
coinsurance, copays and expenses that exceed plan limits. Employees may defer up to $2,500
pre-tax per year.
If you are enrolled in the Blue Shield HDHP plan you are not able to enroll in the Medical Expense Reimbursement Account.
Dependent Daycare Reimbursement Account
This plan is used to pay for eligible expenses you incur for child care, or for the care of a disabled dependent, while you work. Employees may defer up to $5,000 pre-tax per year.
Example:
Dan estimates that he will have approximately $1,200 in out-of-pocket health care expenses
next year and is looking to increase his take-home pay.
Without the
Health Care FSA
With the
Health Care FSA
$35,000
$35,000
Pre-tax Health Care FSA
$0
$1,200
Taxable Gross Income
$35,000
$33,800
Payroll Taxes (at 30%)
$10,500
$10,140
Health Care Cost
$1,200
$0
Net Pay
$23,300
$23,660
$0
$360
Gross Pay (Annual)
Annual Net Pay Increase
Note
Your current FSA elections will expire on June 30th. If you plan to participate in the FSA for the
upcoming plan year, you are required to re-enroll.
14
ONLINE MEMBER PORTAL
With MyCVT, you and your family can access your medical benefits information whenever you want, from home or any place
where you have internet access. Use MyCVT to make your benefit elections, update your personal information, and to locate important benefits documents on the Resource Library.
User Login:
 Website Address: https://mycvt.cvtrust.org
 To create an account, click on the “Create Account” link under the login fields. Enter information required to create an account:
o Email address that is unique to you
o Your District name or group identifier
o Your social security number
 An email will arrive in the mailbox provided. Open the email and click on the link to complete the registration and access the
portal.
 You should now be logged into the MyCVT portal. Please remember your account login for all future visits.
 To start your enrollment click on “Apply for Coverage”.
It is very important that each employee login to MyCVT and verify their personal information, elect or decline benefits, and identify a life insurance beneficiary.
15
TENTATIVE EMPLOYEE CONTRIBUTIONS
This chart compares the tentative tenthly contributions for our employee benefit plans based on the 2013-2014 agreement. Your
cost for coverage will vary depending on the option and level of coverage you choose. Employee contributions for Medical are
deducted from your paycheck with pre-tax dollars. This means that contributions are taken from your earnings before taxes –
resulting in lower taxes and increased take home pay.
25% Premium Discount: If you have double coverage through a CVT medical plan, due to you and your spouse both being active
CVT PPO subscribers, both employees will receive a 25% decrease on their monthly medical premium. This applies when both
employees are enrolled in a CVT PPO plan and the discount is based on the basic PPO composite premium.
Hours Per Day
50%
60%
80%
100%
District Pays
Employee Pays
50%
50%
60%
40%
80%
20%
100%
0%
$874.58
$780.98
$941.97
$873.57
$789.57
$1,093.42
$1,029.82
$842.95
$771.12
$932.62
$782.37
$688.77
$825.32
$756.92
$672.92
$977.54
$913.94
$714.18
$681.98
$816.74
$597.96
$504.36
$592.02
$523.62
$439.62
$745.79
$682.19
$456.64
$503.70
$584.99
$413.55
$319.95
$358.73
$290.33
$206.33
$514.04
$450.44
$199.10
$325.43
$353.24
$77.00
$75.38
$64.63
$62.24
$60.21
$52.44
$32.73
$29.86
$28.05
$3.21
$0.00
$3.66
$6.12
$16.40
$4.76
$13.91
$2.03
$8.94
$0.00
$3.97
Medical Benefits
Kaiser Traditional HMO
Kaiser HMO Wellness
Blue Shield HMO Plan 1
Blue Shield HMO Plan 2
Blue Shield HMO Plan 3
Blue Shield PPO Plan 3B
Blue Shield PPO Plan 5B
Blue Shield PPO Plan 7B
Blue Shield HDHP PPO
Blue Shield PPO Wellness
Dental Benefits
Delta Dental PPO
Delta Dental PPO Incentive
MetLife PPO
Vision Benefits
MES Vision
VSP Vision
HSA Contribution (Distribution July & January)
Single
Family
16
$1,200
$2,400
RESOURCES AND CONTACTS
Below is a list of insurance carrier contacts should you require assistance with your benefit
questions following open enrollment.
California’s Valued Trust (CVT)
Member Services ………………………....……………………… (800) 288-9870
CVT Website …………………………………..…………………… www.cvtrust.org
Medical - Kaiser Permanente
Member Services ……………………………………….………… (800) 464-4000
Chirometrics - Chiropractic Member Services …….… (877) 519-8839
Kaiser Permanente Website ………………………………... www.kaiserpermanente.org
Medical - Blue Shield
HMO/PPO Member Services ………………………………..
HMO/PPO Pre-Admission / Prior Authorization ……
HMO/PPO NurseHelp 24/7 ……………………………………
PPO Claims Processing (Healthcomp) ……………………
PPO Blue Card Program (outside California) …….……
PPO Health Management Program (Alere) ……………
Blue Shield Website ………..…………………………………...
Prescription Drugs (CVS Caremark) ………….……………
CVS Caremark Website …………………………….……………
(888) 235-1765
(800) 541-6652
(877) 304-0504
(800) 442-7247
(800) 810-2583
(877) 864-1327
www.blueshieldca.com
(888) 354-6390
www.caremark.com
Note
If you are unable to
resolve your issues or
questions with the
insurance carriers,
please contact the Risk
Management
Department.
Dental - Delta Dental
Member Services ………………………………………………... (866) 499-3001
Delta Dental Website …………………………………………… www.deltadentalins.com
Dental - MetLife
Member Services …………………….…………………………… (800) 942-0854
MetLife Website ……………………..……………………….…… www.mybenefits.metlife.com/dental
Vision - MES Vision
Member Services ……………………………….………………… (800) 877-6372
MES Vision Website ………………………………….………….. www.mesvision.com
Vision - VSP Vision
Member Services ……………………………….………………… (800) 877-7195
VSP Vision Website …………………………………………….… www.vsp.com
Employee Assistance Program - Value Options
Counselor Services ………….……………………………..……. (877) 397-1032
EAP Website ………………………………………………………… www.achievesolutions.net/cvt
Flexible Spending Accounts - American Fidelity
Member Services ……………………………….………………… (800) 325-0654
American Fidelity Website …………………………………... www.afadvantage.com
Voluntary Products - American Fidelity
Member Services ……………………………….………………… (800) 365-9180
American Fidelity Website …………………………………... www.afadvantage.com
Legal Plan - Hyatt Legal
Member Services ……………………………….………………… (800) 821-6400
Hyatt Legal Website ………………………………………..…... www.legalplans.com
17
NOTES
18
SECTION 125 FLEXIBLE BENEFIT PLAN
Interest Form For New Employees
Please mark the appropriate line and or boxes and return to your American Fidelity Representative.
I would like more information about pre-taxing my benefits under the Section 125 plan.
I would like more information about the following voluntary products:
Accident Only Insurance*, +
Cancer Insurance*, +
Disability Income Insurance*
Permanent, Portable Life Insurance (underwritten by TX Life Insurance Company)*, **
I would like more information on the following reimbursement accounts available through the Section 125 plan:
Medical Expense Reimbursement Maximum $2,500 per Plan Year
Dependent Care Reimbursement Maximum $5,000 per Plan Year ($2,500 if you are married and file a
separate tax return)
I am not interested in participating in the Section 125 plan at this time.
*These products may contain limitations, exclusions and waiting periods.
**Not eligible under Section 125.
+This product is inappropriate for people who are eligible for Medicaid coverage.
I would like to be contacted by American Fidelity Assurance Company to learn more about American Fidelity’s
products and services. With my signature below, I understand that a representative will call me to schedule my
appointments and/or discuss my benefit options.
Print Name
Signature*
Work Phone
Home Phone
Job Location
Classified/Certificated/Mgmt
Date
Date of Hire
*With my signature, I consent to being contacted, including by phone, regardless of my status on any Do-Not-Call list.
AMERICAN FIDELITY ASSURANCE COMPANY
Lola Rosado | CA License #0700334, Ext 365
San Marcos Branch Office | 1 Civic Center Drive, Suite 360 | San Marcos, CA 92069
(866) 523-1857 | (760) 798-7515
19
2211 Michelson Drive, Suite 1200, Irvine, CA 92612 / Telephone: (949) 833-2983 / Fax: (949) 833-9549
www.burnhambenefits.com
This brochure provides an overview of some of your benefit plan choices. It is for informational purposes only. It is not intended to be an
agreement for continued employment. Neither is it a legal plan document. If there is a disagreement between this guide and the plan
documents, the plan documents will govern.
In addition, the plans described in this brochure are subject to change without notice. Continuation of any benefit plan or coverage is at
the company’s discretion and in accordance with federal and state laws. If you need additional information or have any questions about
the benefit program, please contact the Risk Management Department.
Copyright © Burnham Benefits Insurance Services - all rights reserved